Peds Newborn Exam

Table Of Contents
1 General Observation
2 Physical Exam (Head to Toe)
  • Congratulate patient!
  • Is now a convenient time to check your baby?
General Observation
  • Asleep or awake?
  • Warm or cool?
  • Vital signs?
  • Difficulty breathing?
  • Signs of distress or Illness – Contact attending physician
  1. Notice color, posture/tone, activity, size, maturity, and quality of cry.
    1. Ex: an infant has a normal pink color, normal flexed posture and strength, good activity and responsiveness to the exam, relatively large size (> 9 pounds), physical findings consistent with term gestational age (skin, ears, etc), and a nice strong cry.
Physical Exam (Head to Toe)
  1. HEAD: Inspect and palpate the head noting: bruising, edema, molding/shape, sutures, and fontanelles.
    1. CLAMS (top of head)
      1. Coronal suture
      2. Lamboid suture
      3. Anterior fontanelle
      4. Metopic suture
      5. Sagittal suture
    2. Molding – temporary deformation that allows the skull to be malleable enough to fit through the birth canal
    3. Bruises and Swelling
      1. Cephalohematoma (sub-periosteal bleed)
        1. Does NOT cross suture lines
        2. bleeding below periosteum
        3. MC that is assisted with vacuum or forceps
        4. increased risk of jaundice due to the break down of Hgb as the bridge resolves
      2. Caput succedaneum (scalp edema)
        1. Crosses suture lines
        2. Fluid accumulation above the periosteum due to the force of delivery
        3. resolves in a few days of birth
      3. Subgaleal hemorrhage
        1. Extensive swelling that crosses suture lines
        2. bleeding due to rupture of emissary veins
        3. more extensive due to serious blood loss and fills a large space
      4. Cutis aplasia (Back of the head)
        1. a congenital anomaly where the fontanelles are not formed properly
        2. not dangerous
      5. Gentle but firm palpation will help distinguish these three entities from each other and from molding.
    4. Suture frequently overlap each other (“over-riding”) and fontanelle size varies.
    5. Within 24 hours, edema and molding will already show improvement.
  2. FACE: Examine the face:
    1. Evaluate the Eyes for: symmetry, set/shape, discharge, erythema, and red light reflexes.
      1. Eyes should be symmetric and in a normal position.
        1. widely spaced
      2. Eyelid edema is common after birth and resolves a few days.
      3. Palpebral fissures
        1. horizontal 
        2. upslanting
        3. down slanting
      4. Slight yellow discharge in a normal eye may be benign, but injection in the conjunctiva (seen above in the baby’s right eye) is abnormal.
      5. Assess Red Reflex (by shining a light in the retinal vessels)
        1. Red light reflexes can be seen by looking at the pupils through an ophthalmoscope; they may appear orange-yellow in darker-skinned infants.
        2. should appear symmetric red reflex
        3. If Asymmetric red reflex (red and white)
          1. congenital cataract
          2. retinoblastoma
          3. Refer to ophthalmology and medical genetics
      6. Coloboma
        1. missing pieces of tissue in the eye
        2. Refer to ophthalmology and medical genetics
    2. Evaluate the Ears: ear set/shape, preauricular pits/tags
      1. top of ear aligned with the eyes (low set ears = down syndrome)
      2. Helix formation
      3. Crus formation
      4. Pits 
      5. Skin tags
      6. May be associated with genetic conditions, hearing loss, or kidney anomalies
    3. Evaluate the Nose: nasal shape/patency
      1. Assess patency of the nares
      2. Neonates are preferential nasal breathers
      3. If History of respiratory distress? or Noisy breathing when feeding or crying?
        1. placing French catheter thru each nose
      4. Edema from suctioning at birth
        1. Choanal atresia
          1. improper formation of nasal airways
          2. CHARGE
            1. Coloboma
            2. Heart abnormalities
            3. Atresia of the choanae
            4. Retardation of growth/development
            5. Genitourinary abnormalities
            6. Ear abnormalities
          3. Refer to ENT specialist and medical geneticist
        2. Choanal stenosis
          1. partial formation of nasal airways
    4. Evaluate Mouth and Jaw: palate, gums, lips
      1. Insert finger to newborn’s mouth
      2. check for suck reflex – healthy baby will have this
      3. feel the top of the palate (soft palate in the back and hard palate in the front)
        1. Cleft hard palate
        2. Cleft lip
        3. Cleft soft palate
        4. Refer either one to ENT
    5. Evaluate the Tongue
      1. can push past lower gums or elevate
        1. If NOT = Ankyloglossia (tongue-tie)
        2. cannot push tongue past lower gums
        3. impair the ability to breastfeed
        4. Frenotomy is indicated if breastfeeding is painful or inefficient
    6. Ears should not appear low or posteriorly rotated.
    7. Although nasal congestion can be present in newborns, there should not be nostril flaring or respiratory distress.
    8. Palate should be intact visibly and by palpation (submucosal clefts occur).
    9. Tongue should be freely mobile. 
    10. Ex: the lingual frenulum under the tongue is restricting tongue elevation when the baby cries.
  3. NECK: Examine the neck and clavicles for: range of motion, asymmetry, masses, or crepitus.
    1. Infants have very short necks, but they should have a full range of motion from side to side, and the neck should appear symmetric.
      1. Neck webbing
        1. Turner syndrome
      2. Redundant skin in the back of the neck
        1. Noonan syndrome
    2. To palpate clavicles, use a firm, steady pressure along the entire length of the bone, from shoulder to sternum, to detect crepitus, edema, or step-offs that indicate a clavicular fracture.
      1. swelling over the left clavicle could indicate a fracture.
      2. Fractures of the clavicle may occur during delivery, particularly in infants who had shoulder dystocia
  4. Observe Chest: shape of thorax, position of nipples, and work of breathing.
    1. Chest should have a normal contour with nipples near the mid-clavicular line.
      1. Flat
      2. Concave (Pectus excavatum)
      3. Convex (Pectus carinatum)
      4. MC in Marfan Syndrome
    2. Small breast buds are present in term infants.
    3. Breathing should appear easy.
    4. Ex: unusually prominent ribs as a result of intercostal retractions, a sign of respiratory distress.
  5. Listen for and assess: breath sounds, heart murmurs, and femoral pulses.
    1. Lung sounds should be clear and equal.
    2. Auscultate 4 spots on the front and back
      1. Normal respiratory rate is 40 – 60 bpm.
      2. periodic breathing – normal for infants to take short pauses in their breathing, slightly irregular
    3. Listen to 4 spots on the heart:
      1. Normal heart rate is 120 – 160 bpm.
      2. Quality and location of murmurs should be noted.
        1. Patent ductus arteriosus (PDA)
          1. benign
          2. close in a few days after birth
          3. if not resolve after a few days, further eval is needed
            1. pre- and post- ductal oxygen saturations (SaO2)
            2. 4 extremity blood pressures
            3. EKG
    4. Femoral pulses are best obtained when the infant is quiet. They should feel strong and equal.
      1. unable to find a pulse or very weak in one side
        1. Aortic coarctation
          1. measure pre- and post ductal oxygen saturations and four extremity blood pressures
      2. Check for the presence of inguinal hernia
  6. Assess Abdomen: bowel sounds, liver, spleen, kidneys, and umbilical cord .
    1. Bowel sounds should be present and the abdomen soft (not distended)
    2. A liver edge in nornally palpable 1 – 2 cm below the right costal margin.
    3. A spleen should not be detected on physical exam.
    4. Kidneys may be palpated by an experienced examiner, but are likely enlarged if easily felt.
      1. Intra-abdominal neoplasm:
        1. Neuroblastoma
        2. Wilm’s tumor
    5. The cord should be clean and dry.
      1. umbilical hernia 
      2. reducible or not by palpating
      3. Incarcerated – a hernia that feels firm or stuck in place
        1. should be evaluated by a surgical specialist
    6. If fresh, the umbilical vessels may be assesssed also.
    7. There should be two arteries and one vein.
  7. Evaluate Groin: labia, hymen (or penis, testicles), and anus .
    1. For girls, both labia majora and minora should be seen.
      1. Normal hymenal tissue is light pink with a central orifice between the labia minora.
      2. Labia and clitoris may appear engorged as a result of maternal hormones
      3. White or mucoid discharge or a small amount of bleeding is normal.
      4. Vaginal skin tags on the posterior fourchette
    2. For boys, the penile shaft should appear straight with an intact foreskin.
      1. Testicles should be palpable bilaterally as small (1 cm) symmetric masses.
      2. Swollen around the testicles – Hydrocele
        1. a fluid collection around the testes which will spontaneously resolve
      3. Examine the penis
        1. abnormal curvatures
        2. foreskin should fully cover the glans
        3. Hypospadias
          1. the hooded foreskin, the ventral displacement of the urethral meatus
    3. The anus should have a visible orifice within the sphincter. Stool in the diaper is not evidence of patency.
      1. Assess the patency of the anus by using one hand to hold the legs and the other to gently spread apart the gluteal cleft
  8. Inspect extremities for: mobility, deformity, and stability.
    1. Fingers and toes should be counted and evaluated for evidence of malformation. (10 fingers and 10 toes)
      1. 6 fingers (polydactyly)
      2. short fingers (brachydactyly)
      3. long fingers (arachnodactyly)
        1. missing or extra digits = further investigations
      4. Single transverse palmar crease
        1. MC Down syndrome
    2. Arms and legs should appear symmetric bilaterally and have normal position and good tone. 
    3. Hip Dysplasia
      1. congenital deformation or misalignment
      2. MC if :
        1. Family history of hip dysplasia
        2. girls
        3. breech presentation in utero
        4. All neonates with risk factors should have a hip US at 4-6 weeks of life regardless of normal hip exam
      3. Ortolani and Barlow maneuvers are used to evaluate hips for subluxation or dislocation.
        1. Barlow
          1. adduct the knee
          2. push posteriorly to check for posterior dislocation
        2. Ortolani
          1. leg and knee at 90 degrees 
          2. then fold the thighs outward
        3. If you feel clunk or dislocation
          1. F/u with PCP or an ortho surgeon
    4. Ex: newborn has bilateral clubfeet.
  9. Assess back and spine for: symmetry, skin lesions, and masses.
    1. Back should appear symmetric and spine should be palpable all along its length.
      1. Blue-grey macules
        1. common
        2. fade over time
      2. Erythema toxicum
        1. pustules on an erythematous base
        2. appears at 24-48 hours of life
      3. Sacral dimple
        1. check if you can clearly visualize the base of the indentation
        2. if you cannot, the infant may have:
          1. Tethered cord
          2. Spina bifida occulta
      4. Other findings of sacral abnormality:
        1. conspicous patch of hair on the lower back 
        2. asymmetric gluteal cleft
    2. Unusual skin lesions, tags, or masses should be noted as these may indicate underlying spinal dysraphism.
  10. Neurologic: Evaluate the following reflexes: suck, grasp (hands and feet), and Moro.
    1. awake or asleep
    2. irritable or calm
    3. consolable or inconsolable
    4. Motor function
      1. assess by observation
      2. move all extremities
      3. face symmetric
    5. Sensation
      1. respond to your touch
    6. There are several other reflexes present at birth, but unless there is concern about the neurologic state of the infant, a general screening with the items listed above should be sufficient.
      1. symmetric
        1. if asymmetric = neurologic or orthopedic condition
      2. grasp hands
        1. hypertonic (head come up with body)
        2. hypotonic (does head lag behind)
      3. Moro Reflex
        1. hold the infant and pull forward until a few cm above the bassinet
        2. drop her head gently into your other hand
          1. hands should open
          2. upper extremities should extend then retract
      4. Palmar Grasp reflex
        1. put your finger into the infant’s palm 
        2. infant will wrap his/her fingers around yours
      5. Rooting Reflex
        1. tapping infants cheek
        2. infant will try to suck your finger
  • change diaper
  • re-swaddle baby
  • thank family for examining baby
  • ask family for any questions